CITY OF MANSFIELD                                      INCOME TAX RETURN
         P.O. BOX 577                                                                      
         INCOME TAX DIVISION                                         YEAR 2022                               INDIVIDUAL 
         MANSFIELD, OHIO 44901                                  FILE BY APRIL 18, 2023                       PAY BY PHONE: 419-755-9711 option 2
                                               ATTACH FEDERAL EXTENSION IF                                   PAY ONLINE: www.ci.mansfield.oh.us                           
                                                                                                                                                      Inc. Tax Dept. Page
         TELEPHONE (419) 755-9711                   FILED AFTER APRIL 18TH                                   DROP OFF BOX: 1st Floor and Court Entrance
                FAX (419) 755-9751 

         Name ____________________________Primary Soc Sec #                                     _________________                         Birthdate ________________
         Name ___________________________________ Spouse  Soc Sec # ______                      _______________  Birthdate __________ ______

         Address ____________________________ City _________________________ State __________  Zip ___________

         PARTIAL YEAR RESIDENT:  DATE MOVED INTO MANSFIELD _______________  _DATE MOVED OUT OF MANSFIELD _____ ______                                                    _____
         DID YOU FILE A CITY RETURN LAST YEAR?    Yes                                  No 
         SHOULD YOUR ACCOUNT BE INACTIVATED?  Yes             No            If Yes explain __________________________________________ 
         FILING STATUS:                                                               NON-FILING STATUS:  NO TAXABLE INCOME
          INDIVIDUAL/MARRIED FILING SEPARATELY                                                         UNDER 18 – ATTACH PROOF OF BIRTHDATE
          JOINT – BOTH SIGNATURES REQUIRED                                                             RETIRED-DATE  _______________________   
         CALCULATE      1.  TOTAL W-2 WAGES (FROM WORKSHEET A) (Important: Attach all W-2’s & W-2Gs and 1040, 1040A or 1040EZ)……..                                       $__________ 
         TAXABLE 
         INCOME         2.  OTHER INCOME (FROM WORKSHEET B) …………………………………………………………………………………………………………………………..                                                             $__________ 
                        3.  TOTAL INCOME (ADD LINES 1 AND 2) ……………………………………………………………………………………………………………………………..                                                           $__________ 
                        4.  ADJUSTEMENT (FROM WORKSHEET C) ……..…………………………………………………………………………………………………………………….                                                             $__________ 
                        5.  SUBTRACT LINE 4 FROM LINE 3   ……………………………..…………………………………………………………………………………………………..                                                           $__________ 
                        6.  PRIOR YEAR(S) CARRYOVER LOSS (SEE INSTRUCTIONS)..……………………………………………………………………………………………                                                         $__________ 
                        7.  MANSFIELD TAXABLE INCOME (SUBTRACT LINE 6 FROM LINE 5)……………………………………………………………………………………                                                       $__________ 
                        8.  MANSFIELD INCOME TAX (MULTIPLY LINE 7 BY .02)……………………………………………………………………                                                                      $__________ 
         ___________ 
         CALCULATE      9.  CREDITS:  A. MANSFIELD INCOME TAX WITHHELD BY EMPLOYERS………………………………………………                                                  $___________ 
         TOTAL TAX 
         CREDITS               B.  ESTIMATED TAX PAYMENTS AND/OR PRIOR YEAR CREDITS……………………………………                                                      $___________ 
                               C. RESIDENTS ONLY INCOME TAXES PAID TO OTHER CITIES (SEE INSTRUCTIONS–Limit 1%)                                         $___________ 
                               D.  TOTAL CREDITS (ADD LINES 9A THROUGH 9C)………………………………………………………                                                                          $___________ 
                        10.  TAX DUE (SUBTRACT LINE 9D FROM LINE 8)…………………………………………………………………………                                                                          $___________ 
                        11.  LATE FILING FEE ($25.00 EACH MONTH FILED LATE UP TO MAXIMUM OF $150.00) ………………….                                                            $___________ 
                               LATE PAYMENT PENALTY (SEE INSTRUCTIONS TO CALCULATE)             IF PAID AFTER DUE DATE                                                   $___________ 
                               INTEREST (PLEASE SEE INSTRUCTIONS TO CALCULATE) IF PAID           AFTER DUE DATE                                                          $___________ 
                        14.  TOTAL DUE (IF $10.00 OR LESS - DO NOT PAY) (ADD LINES 10, 11, 12            and 13)…………………                                                  $___________ 
          ____________  
          OVERPAYMENT  15.  OVERPAYMENT CLAIMED:  TO BE REFUNDED $ ___________  CREDITED TO NEXT YEAR $____________

                                        DECLARATION OF ESTIMATED MANSFIELD, OHIO CITY INCOME TAX FOR 2023 
         16. Total income subject to tax $ _________________ multiply by 2.00% (2023 tax rate) …………………………………………………………………………                                              $ ___________ 
         17. Estimated credits (tax withheld, paid by partnerships, paid to other cities)…………………………………………………………………………………………………                                           $ ___________ 
         18.  Net Tax Due (line 16 less Line 17) …………………………………………………………………………………………………………………………………………………………………                                                           $ ___________ 
         19.  First installment of declaration (Multiply line 18 by at least 22.5%)……………………………………………………………………………………………………………                                             $ ___________ 
         20. Less overpayment from line 15 above: ($...............................) = Balance due with return …..……………………………………………………………                                $ ___________ 

         21. TOTAL AMOUNT DUE (ADD Lines 14 and 20)………………………………………………………………………..                                                                PAY THIS AMOUNT          $ _________ 
          IF THIS RETURN WAS PREPARED BY A TAX PRACTITIONER, CHECK HERE IF WE MAY CONTACT HIM/HER DIRECTLY WITH QUESTIONS REGARDING THE PREPARATION OF THIS RETURN. 
         The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated and that the figures 
         used herein are the same as used for Federal income tax purposes.  The return must be signed and dated.  JOINT RETURNS REQUIRE BOTH SIGNATURES 
         _______________________________________________ ________________________              _______________________________________________ __________________________ 
         SIGNATURE OF TAXPAYER (PRIMARY)                           DATE                              SIGNATURE OF PREPARER, IF OTHER THAN TAXPAYER                       DATE 

                    ______________________________________________ _________________________   ______________________________________________  _________________________ 
         SIGNATURE OF TAXPAYER (SPOUSE)                                          DATE                EMPLOYER AND ADDRESS OF PREPARER                                    PHONE # 

WORKSHEET A   – SALARIES AND WAGES (W2 INCOME) 
                             Column 1                                        Column 2             Column 3              Column 4 
                           Employer, City, State                           Income From       Mansfield Tax        Other City Tax 
                                                                             Each W-2             Withheld              Withheld 
A. 
B. 
C. 
D. 
Totals 

WORKSHEET B – OTHER INCOME 
1. Schedule C (Income found on your federal schedule C)

                (A)                                       (B)                            (C)                 (D)        (C times D) 
             Business Name                        Business Address                    Net Profit/            Allocation Amount 
                                                                                         (Loss)            Percentage   Subject to Tax 
A. 
B. 
                                                                                         TOTAL (1)    $___________________ 
2. Schedule E – Income From Rentals (Income found on your federal schedule E)         TOTAL (2)            $ ___________________ 
3. Schedule O – Other Income Not Included in Schedules C or E (Income from Partnerships, Estates, Trusts, S-Corp, Tips, 1099’S, etc.)
Received From Name/ID#                           For (Description and/or Location)                                Amount 
A. 
B. 
                                                                                      TOTAL (3)   $ ___________________ 
TOTAL OTHER INCOME    (ADD LINES 1 – 3) ENTER HERE AND ON LINE 2 (ON FRONT)             TOTAL         $ ___________________ 

NOTE:    The  net  loss  from  an  unincorporated  business  activity  may  not  be  used  to  offset  salaries,  wages,  commissions  or  other 
compensation (W-2 statement).  However, if a taxpayer is engaged in two or more taxable business activities to be included on the same 
return, the net loss of one unincorporated business activity may be used to offset the profits of another for purposes of arriving at overall 
net profits. (Line 5 (on front) cannot be less than zero, if you have W-2 income). 

WORKSHEET C – ADJUSTMENTS TO INCOME (Part year residents, credits for taxpayers 65 and older, income 
not subject to tax, etc. See instructions for detail) 

                                          Explanation                                                            Deductions 

                                                         Net Adjustment (enter on Line 4 on front)         $ 

ATTACHMENTS REQUIRED WITH ALL RETURNS:  W-2’S AND FEDERAL 1040 

IMPORTANT:  It is mandatory to file a declaration of estimated taxes and make estimated payments if you expect to owe $200.00 or 
more in taxes, also please read instructions on who must file and what is taxable or non-taxable income.